Adult Medical- Surgical Nursing Gastro-intestinal Module: Diverticular Disease: (Diverticulosis/ Diverticulitis)

Diverticular Disease: Incidence and Aetiology A condition of the colon, often affecting the sigmoid Mostly found in the elderly Associated with a low fibre diet, dehydration, constipation and straining to defaecate The elderly often present with diverticulitis, inflammation and infection of the colon

Diverticular Disease: Pathophysiology With straining to defaecate, the submucosal and mucosal layers of the colon herniate through the muscle forming pockets (diverticulosis) The pockets can trap faecal matter and become inflamed (diverticulitis) Local inflammation → bowel irritability/ spasticity Abscesses may form, which may: Perforate → peritonitis (acute abdomen) or Erode a blood vessel (haemorrhage and malaena) Healing causes fibrosis and strictures, increasing constipation and risk of sub-acute or acute obstruction

Diverticulosis: Clinical Manifestations Left-sided lower abdominal pain Nausea/ anorexia Low grade fever Abdominal distension Constipation Weight loss/ malnutrition

Diverticulitis: Clinical Manifestations Acute, severe pain in the left lower abdomen Fever (may lead to septicaemia: hyperpyrexia and rigors) Constipation (may be silent bowel: no bowel sounds) If perforation, symptoms of peritonitis (shock) Rectal bleeding and malaena

Diverticular Disease: Medical Treatment Rest the bowel while inflamed (clear fluids) → once settled, a high fibre, low fat diet Antibiotic course Bulk-forming laxative (Fybogel) Anti-spasmodic (Probanthin, Buscopan) Pain relief (avoid codeine as constipating) Stool-softening agent when hard, or glycerin suppositories

Diverticulitis: Emergency Treatment 25% of patients with diverticulitis require immediate surgical intervention for an “acute abdomen”: perforation, abscess, peritonitis, haemorrhage, obstruction Antibiotic cover Surgical resection with end-to-end anastamosis Resection with double-barrel colostomy and later anastamosis If sub-acute, antibiotics and elective “cold” surgery may be required later

Diverticular Disease: Nursing Considerations Patient teaching about diet, exercise and bowel habit If surgery required: pre- and post-operative nursing of a patient undergoing bowel resection Colostomy care and patient education: Observe stoma is healthy (active, red & shiny) Care of colostomy and surrounding skin Management of diet with colostomy

Diverticular Disease: Bowel Resection Pre-operative Care Emergency operation: General physical check-up, chest Xray, ECG Blood profile, IVI, group and cross-match (GXM) Breathing exercises to prepare for post-op Thrombo-embolism stockings/ prophylactic heparin Explanation of operation and possible stoma, consent and emotional support Nil orally pre-op

Bowel Resection: Post-operative Care Regular pain relief Monitor vital signs, pulse oximetry, IV fluids, urine output and fluid balance Semi-sitting position once recovered Breathing and leg exercises. Early ambulation Low molecular dose heparin. IV antibiotics Nil by mouth (NPO) initially→ graduated intake (mouth care) Nasogastric tube aspirations, wound, drain care, stoma care